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The Great Influenza:

The Epic Story of the Deadliest Plague in History

About this book

Based on a large number of historical data, the author redraws the occurrence, development and global ravaging process of the 1918 pandemic flu.
This book describes in detail the process of interaction between science, politics and the spread of disease, and deals with the important milestone in the evolution of traditional medicine to modern medicine, as well as the courage, values, research attitudes and methods shown by scientists and medical workers under great pressure.

Core content

This book is about the pandemic flu that ravaged the world in 1918.
The pandemic originated in Haskell County, Kansas, and gradually spread around the world, with only a few isolated places avoiding the plague.
There were three waves of pandemic influenza, the first of which occurred in the spring of 1918 and did not disappear until the spring of 1920.

At that time, the world’s population was less than 2 billion, and the pandemic infected 30 per cent of the world’s population.
How many people died from the pandemic?
There is no clear answer to this question.
The most conservative estimate was 25 million, and later epidemiologists estimated the death toll at 50 million.

Why is there this pandemic?
Later epidemiological experts analyzed that the bird flu virus carried by birds could not be transmitted to humans, but in the intermediate host, the avian influenza virus and human influenza virus rearranged their genes to form a new virus that can be “transmitted from person to person”, that is, H1N1 influenza virus.
One of the hosts is the pig.
Virologists call pigs the “mixing bowl” of viruses because they can infect both poultry and human influenza viruses, and pigs are too close to humans.

The SARS virus comes from bats, and the Ebola virus also comes from bats, all of them are transmitted to humans through intermediate hosts.
COVID-19, who broke out in Wuhan, is also in this way.
Today’s medicine can estimate that there are about 160000 viruses hidden in nature, but we only know 3000 of them, and the future plague is likely to be some unknown virus spreading among humans.

The atmosphere described in this book is suffocating.
The pandemic killed many people. For example, 12 million people died in India alone.
When the plague spread, the city collapsed, the doctors were fail, and the scientists were helpless.
Paying attention to the extreme situation faced by mankind in the past can help us better think about and face the current situation.

1. How did the pandemic break out? Did the pandemic flu end World War I?

In 1918, World War I was still going on.
When the United States announced its entry into the war the year before, the whole country was inspired by patriotic passion, and the military had a great demand for doctors and nurses.
Among the medical school graduates not long after graduating at that time, the best were selected for the army.

The problem that doctors are most concerned about in the army is infectious diseases, because in many wars in the past, more soldiers died of illness than in the war.
In addition to doctors, top medical scientists also joined the army and were awarded the rank of major.
For research institutions such as the Rockefeller Medical Institute, the entire establishment has joined the United States Army.

At that time, medicine had defeated the infectious disease diphtheria and could fight typhoid, cholera, yellow fever and the Black death.
Military Medical Director Gogarth has prepared a large number of typhoid vaccines for the army, including smallpox vaccine and immune serum against pneumonia, dysentery and meningitis, but there is no vaccine against measles.
As a result, measles first broke out in the barracks.
At that time, the living conditions in the barracks were so poor that they could not meet the minimum public health standards. coupled with the fact that a large number of young people gathered together, it was a hotbed of infectious diseases.
The most serious complication of measles is pneumonia. From September 1917 to March 1918, more than 30,000 American soldiers contracted pneumonia and more than 5,000 died.

Then came the first wave of pandemic flu.
In early March 1918, several young men from Haskell County, Kansas, were recruited into the Forston Barracks.
Soon, someone in the barracks began to catch the flu.
Within three weeks, more than a thousand people in the barracks needed hospitalization.
In the spring, 24 of the 36 barracks in the United States were hit by the flu.
However, the severity of the flu is not comparable to that of pneumonia caused by measles.
In April, when the flu entered Europe, more than 30,000 people in the British first Army alone were hospitalized, and more than 10,000 sailors in the British fleet fell ill, but the mortality rate was not high at this time, and medical workers did not pay special attention to it.

Some pathological reports show that the flu is so severe that some soldiers will die within two days.
Their cause of death was explosive pneumonia.
In late May, a report showed that an epidemic occurred in a small barracks with only more than 1,000 people in France, 688 people were hospitalized, 49 died, and the death rate reached 5%.
By June and July, there were about 2 million British soldiers stationed in France, of whom 1.2 million were ill, but they slowly recovered.

The mortality rate of the first wave of influenza is not high.
The patient was lucky enough to acquire antibodies to resist the second wave of influenza.
But the virus is slowly changing.
After “passage”, the virus is more adaptable to the human environment, and the lethality is also significantly improved. As a result, the second wave of influenza attacks become more violent and deadly.
On June 30, 1918, the British cargo ship Exeter City arrived in Philadelphia, USA. A large number of crew members got sick. Ambulances took the crew to hospital, and the crew died one after another.
London also reported on July 8 that 287 people had died of flu-induced pneumonia in a week.
The outbreak is like boiling water, starting with a bubble, and then two or three bubbles appear at the same time, more and more bubbles, and a pot of water boils up.
This is how the pandemic flu began to roll around the world.
Since August, the number of cases of pneumonia caused by influenza has skyrocketed among the US military.

On August 12, a Norwegian freighter arrived in New York. All 200 sailors on board got the flu and they were taken to hospital.
In response, officials from the New York Department of Health said there was absolutely no risk of an epidemic.
Subsequently, three more foreign ships arrived in New York.
New York newspapers reported that the crew were taken to hospital after a flu outbreak on board the ship arriving in New York.
On August 20, health officials admitted that there was flu in New York, but it was not too serious and could be prevented and controlled.

In the world 100 years ago, there were not as many planes and people moving so fast as there are today.
Unfortunately, it was a time of war, and busy troop carriers and cargo ships accelerated the spread of the epidemic. Coupled with the small space on board, it was simply a “moving coffin.”

The outbreak broke out with the confluence of ships.
Freetown, the capital of the West African country of Sierra Leone, was an outbreak point, where European ships bound for South Africa had to add coal.
On August 15, a British Navy warship came here to replenish coal. 200 sailors on board had contracted the flu. Local workers in Freetown were infected when they added coal to the warship, spreading the flu to the locals.
On August 27, another British navy ship came to replenish the coal, only to find that 500 of the 600 local workers were absent from work.
The crew worked with local workers, and as a result, 600 of the ship’s 779 crew fell ill and 51 died, meaning a mortality rate of 7%.
At the same time, a troop carrier from New Zealand was also refueling coal here. 900of the 1150 people on board fell ill, and the final death rate was 38 per cent.

Talking about going back to America.
At the end of August, an outbreak occurred on a ship on Boston’s wharf.
There were 7000 people on board, 58 of whom were diagnosed with illness and taken to naval hospital.
Military doctors took quarantine measures, but the epidemic began to spread in Boston.
60 kilometers outside Boston, there is a Devens barracks, home to 45000 soldiers.
The barracks hospital can hold 1200 people and has sufficient medical staff.
At the beginning of September, there were only 84 inpatients in the barracks hospital, but 6000 soldiers checked in at the end of the month.
On September 24 alone, 342 people were diagnosed with pneumonia.
One military doctor said in a letter to his colleague that an average of 100 people die every day. These people start out as if they had the flu, but their condition quickly deteriorates to malignant pneumonia and cyanosis that they have never seen before.
Cyanosis means that the lungs are unable to exchange oxygen with the blood, and the skin turns black and purple.

For a while, rumors spread that it was not the flu, but the Black death.
Top US medical experts also arrived at the Devens barracks. They saw hospitals full of camp beds, patients lying on them, blood everywhere, soldiers coughing up blood, or spitting blood out of their noses and ears, and the morgue was full of bodies.
The doctor worked from 05:30 in the morning to 09:30 in the evening, and 70 of the 200 nurses fell ill.

Among these medical experts is William Welch, a leading figure in American medicine and a professor at Johns Hopkins University.
He judged that it was a new infectious disease, and he made three calls from the Devens barracks, the first of which asked a top pathologist to dissect the body and find clues to the disease.
The second call was made to Avery, an expert at the Rockefeller Institute of Medicine, who had been studying pneumonia.
A third call was made to the military Medical Service to report that the disease would quickly spread to military barracks.

At that time, a military doctor published a paper describing the symptoms of pandemic flu, saying that the disease would spread rapidly across the country and would affect 30% to 40% of people in the United States.
The military doctor was right, except that the word “United States” should be changed to “the whole world”.

2. How does Philadelphia deal with the epidemic? How did the 1918 pandemic flu spread in Philadelphia, USA?

Before World War I, Philadelphia had a population of 1.75 million, and the shipbuilding industry allowed more workers to enter the city, but Philadelphia’s public facilities were poor.
On September 15, 1918, 600 seriously ill sailors were admitted to the Philadelphia Naval Hospital.
Two days later, the plague spread to the city, and five doctors and 14 nurses fell ill in a civilian hospital.
In this regard, Philadelphia Health Department official Cruisen insisted that the flu will not pose too much threat to Philadelphia.
The newspapers also reassured the public that the flu could be controlled.
On September 21, the Health Bureau advised the public that if they want to avoid the flu, they should keep warm, keep their feet dry and keep their bowels unobstructed.
A week later, a big parade will be held in Philadelphia to sell multimillion-dollar war bonds, the largest parade in Philadelphia history, with thousands of people and hundreds of thousands of onlookers.
The day before the march, hospitals in Philadelphia accepted 200 flu patients, 123 of whom were citizens.
Despite repeated calls from doctors to cancel the march, health official Krousen allowed the rally to proceed as usual.
Crusoe promised that there would be no danger to onlookers.

A few days later, the health official made another speech, saying that it is not good that there is a pandemic flu among civilians.
The incubation period for the flu is 24 to 48 hours, and within three days, or 72 hours, of the end of the parade, 31 hospitals in Philadelphia were full.
On the third day of the march, 117 people died of influenza, which was October 1.
By October 3, Crusoe banned all public meetings in Philadelphia.

A few days ago, Crusoe approved the parade.
Now he has closed churches, schools and theatres.
There are also signs on the street that read, “spitting equals death”.
The number of confirmed cases has risen rapidly from hundreds to thousands every day.
On October 6 alone, 289 people died of the flu.
Since then, the daily death toll has reached more than 300.
Crusoe comforted the citizens that the death rate would drop soon.
But then the death toll rose to 428.

The custom in Philadelphia at that time was: “if someone in the family dies, hang a piece of silk cloth at the door, hang white silk cloth if young people die, hang black silk cloth if they are middle-aged, and hang gray cloth if they die old people.”
The naughty children in the city went everywhere to see whose house had hung silk cloth.
People died like flies, and it became a hassle to dispose of the bodies, and there was too much backlog in the morgue to bury them.
People who live in cheap apartments can only park their bodies at home.
The city government sent police to collect the bodies, but 33 police officers fell ill and died.

Eight doctors and 54 nurses fell ill at Philadelphia General Hospital, accounting for 43% of the total health care staff. in the end, 10 nurses died in the hospital.
To replenish staff, juniors and seniors from five medical schools in Philadelphia have received emergency training.
The training teacher, an infectious disease expert, said to the students about the antitoxin and serum at that time, “this is useless, that is useless, it is all useless.”
He is telling the truth that no medicine can effectively deal with the flu.
The doctor went to the hospital and saw 1/4 patients die every day, and new patients checked in the next day.
The whole city was shrouded in fear, with no people on the streets, no cars.

Wealthy families in Philadelphia, which dominate the city’s charities, have set up emergency centers and 24-hour telephone calls.
Because 1800 employees of the telecommunications bureau have fallen ill and are unable to work, the daily telephone lines have been cut off and only emergency calls can be made.
But it’s no use setting up a call for help.
There is a log of an aid organization that records that 2758 of the 2955 calls received one day failed to provide any service, that is, 93% of the people who called for help were unserved.
People need medical staff, but there are no nurses in the city.

Charities are offering higher salaries to recruit doctors from across the country, but the epidemic has spread in the United States and access to doctors is limited.
Health official Crusen issued an announcement, hoping that women in good health would join the emergency team, but there was no response, only nuns went to the hospital to work as nurses.
It is estimated that 500000 people fell ill in Philadelphia at that time, healthy people had to take care of their families, and people lived for themselves without trust in each other.
Volunteers will take doctors to and from work and help in the kitchen, but few people are willing to contact patients.
Charities recruit people to dispose of dead bodies at a salary of $10 a day, which was a high daily salary at the time.
Charities also have to consider how to house a large number of orphans.
759 people died in Philadelphia on October 10th.
By October 16th, the death toll for the week was 4597.
This is the peak of the death toll, and then it begins to decline.

Philadelphia may be the most collapsing place in the United States during the pandemic.
In the United States, the pandemic killed an estimated 650000 people.
The United States is in a flu panic, and the Minister of Health warns that as long as you maintain good hygiene, you can avoid the flu, don’t spit, don’t sneeze, don’t be afraid, and so on.
But more and more cities are shutting down public places, and rumors abound, and some people say that this is not the flu, but a weapon developed by the Germans to spread disease and death through pathogens. This kind of popular sentiment is so strong that the laboratories of the health department actually investigate the possible vectors used in germ warfare, such as aspirin made by Bayer.
Philadelphia is also seen as the birthplace of the plague. a Philadelphia salesman went to Alabama and was arrested by locals suspected of being a German spy for spreading flu. although there was insufficient evidence, he was later killed in a hotel.

Medical journals publish obituaries of medical staff every week.
The Ministry of Health and the Red Cross receive numerous telegrams every day, asking everywhere to send doctors and nurses.
Doctors also show his or her “special prowess” when they treat patients.
They use morphine, aspirin and quinine for malaria on patients.
Some doctors will inject all known vaccines into patients.
Many doctors say their treatments are effective.
One doctor even injected 25 critically ill patients with hydrogen peroxide for disinfection. 13 of the 25 patients got better and 12 died.
And the doctor even claimed that his treatment was effective!

The flu has brought chaos, but there is also a brilliance of humanity in the chaos.
The book specifically mentions a man named Ward, a former surgeon whose original job was to treat work-related injuries to workers in Kansas City.
After retiring in 1914, he bought a small farm in Texas near the Mexican border. He didn’t tell outsiders he was a doctor.
But when the flu hit, the farm workers got sick and Dr. Ward saw them.
One morning, his wife was awakened by the noise outside and came out to see hundreds of Mexicans, old and young, who came to see them for medical treatment. Mr. and Mrs. Ward boiled water, cooking and nursing treatment for the patients on their farm.
After the plague, Ward returned to Kansas City and became a doctor again.
Ward is like Dr. Leah in The Plague Novel by Albert Camus, doing his duty and improving himself in the plague.

3. The response of the medical community to the pandemic flu: why is scientists’ understanding of the virus so slow?

At the time of the 1918 pandemic, the medical staff at the forefront of the battle were graduates of Johns Hopkins University and scientists at the Rockefeller Institute of Medicine.
The history of the development of these two famous institutions shows us that it takes time for a country to improve its medical standards and medical research.

The first chapter of the book is about the inauguration of Johns Hopkins University in September 1876.
Forty years before the pandemic, banker John Hopkins died, leaving a fortune of $3.5 million and donating to build a research university.
In the United States at that time, there were much more theology professors than medical professors, medical research received very little money, and American medicine lagged behind Germany.

In 1901, John Rockefeller Jr.’s grandson died of scarlet fever, and the Rockefeller family set up a large sum of money to set up the Rockefeller Medical Institute to focus on medical research.
Today, Johns Hopkins University’s medical major is among the top in the world, and Johns Hopkins Hospital is one of the best hospitals in the United States.
The Rockefeller Medical Institute also became Rockefeller University.
This is the driving force of money and a good thing left to the world by the rich.

Then chapters 2 and 3 of the book write about William Welch, the medical expert we mentioned earlier.
Born in 1850, he studied chemistry at Yale University, then went to Germany to study medicine, returned to the United States to teach at Bellevue Medical School, and then to Johns Hopkins University, where his students worked at the Rockefeller Institute of Medicine.
Around Welch, a crystal of the medical elite is formed, stable and tight, and everyone has a sense of mission.

Welch was nearly 70 years old when the 1918 pandemic broke out, and he spent much of his time recuperating in Atlantic City after inspecting the epidemic at the Devens barracks.
Although the achievements of medicine are handed down from generation to generation and rational progress is encouraging, scientific research need constant effort brings success., and it takes a little bit of accumulation to make progress.
The following medical researchers and pandemic flu stories can give us a better understanding of this.

In 1908, Paul Lewis, a member of the Rockefeller Medical Institute, discovered and confirmed that polio, is caused by a virus.
He developed a vaccine that was tested only on monkeys with a 100% effect.
But a polio vaccine that can be used in humans will not be available for half a century.
Ten years later, Paul Lewis, who had become a major, was invited to Boston to check on pandemic flu patients, draw blood, test urine and sputum, and clear his throat.
His treatment plan is to draw blood from recovered patients, extract serum, and then inject them.
Lewis is a laboratory worker, not a clinician, and his job is to find the pathogen, find the cause, and, if possible, develop an antiserum or vaccine.
He can tell that this kind of flu is very different from the previous flu.

At that time, the common understanding of influenza in the medical community was that influenza was caused by influenza bacilli, and Lewis isolated pathogens from cases, including influenza bacilli, type I and type II pneumococci, and hemolytic streptococci.
He prepared a small batch of vaccines against these microbes and achieved some results in human trials, but he could not give a scientific explanation.
He suspected that the flu was caused by a virus.

When the pandemic flu gradually subsided, the medical profession in the United States set up a pandemic influenza committee to collect information and continue its research.
They admit that it is a shame that medicine does not have a correct understanding of the pandemic flu.
Lewis later joined an animal pathology institute at Princeton University. He had a chance to go to a university with a high salary and a tenured professorship, but he still wanted to understand the pandemic flu.
Unfortunately, his research was not successful.
In 1929, Lewis died while studying yellow fever in Brazil.

However, his student Richard Shopp discovered the swine flu virus in the 1930s, and then he found that people who had experienced the 1918 pandemic had antibodies to swine flu, while children born after 1920 had no antibodies to swine flu.
Staff at the Institute of Animal Pathology understood that the 1918 pandemic was caused by a virus.
This has been more than a decade after the pandemic.

As we mentioned earlier, the second call made by William Welch at the Devens barracks was to Avery of the Rockefeller Institute of Medicine, an expert on pneumonia.
Many patients died of pneumonia caused by the 1918 pandemic.
As a research expert, Avery’s job is also to find pathogens.
Some laboratories around the United States can find influenza bacilli and some cannot find influenza bacilli. Avery proved through experiments that the primary infection cannot be attributed to influenza bacilli. Influenza bacilli and pneumococci may have invaded the human body after the patient was knocked down by the virus.
He focused his research on pneumococci and went to work in the lab every day.
His research work continued until the 1930s and 1940s.
Between 1934 and 1942, he was over sixty, did not publish any papers, nominally retired and became an honorary member of the institute.

As a result, in April 1943, he informed the Scientific steering Board of the Rockefeller Institute of Medicine that his findings would change biology.
Three months later, the paper was published in the Journal of Experimental Medicine.
Avery was 67 years old when the paper was published.

Let’s see what Avery found.
DNA, or deoxyribonucleic acid, was isolated by a Swiss scholar in 1868, but no one knows its function. The molecule looks too simple.
Geneticists had previously believed that proteins carry the genetic code and the molecular structure of proteins is complex, but Avery’s paper proves that it is DNA that carries genetic information, and the gene is on DNA.
It has been commented that the Dark Ages of DNA ended in the hands of Avery in 1944.

In 1953, Crick and Watson discovered the structure of DNA. In their classic book The Double Helix: A Personal Account of the Discovery of the Structure of DNA, they said, “genes have always been thought of as special types of protein molecules until Avery showed that genetic traits can be transmitted from one bacterial molecule to the next through DNA molecules.”
Avery’s experiment began by looking for a cure for pneumonia and later pioneered the field of molecular biology.
Avery died in 1955, and today one of the gates of Rockefeller University is called the Avery Gate.

Scientific research need accomplish seemingly impossible things by sustained effort, but most people’s understanding of science is focused on the miraculous moment of “accomplish” and do not quite understand the previous “effort”.
This book mentions nearly a hundred scientists and medical workers, and another number is very interesting.
When the plague spread, New York had 21000 orphans whose parents died.
Meanwhile, scientists William Parker and Anna Williams at the New York City Laboratory, which has a total of 220488 utensils to clean and disinfect, are studying pathogens.


First, the pandemic was a plague that began in the spring of 1918, killing 50 million people around the world. Only a few isolated places escaped the plague.
The plague was caused by a virus unknown at the time.
It was not until the 1930s that Richard Shopp proved the harm of swine flu to humans.
Zoonosis is likely to invade the world in the future.

Second, The performance of American bureaucrats is generally disappointing.
Those doctors, police officers, volunteers who scrupulously perform their duties, and those workers who maintain the operation of the city and keep social life from collapsing are heroes.

Third, scientific progress does not happen overnight, and the progress of a country’s medical level and medical research also takes time.
Johns Hopkins University was founded in 1876 and the Rockefeller Institute of Medicine was founded in 1901.
Many of the scientists who fought the plague in 1918 came from these two institutions.

Fourth, Avery has been studying pneumonia.
He demonstrated the genetic role of DNA in pneumococcal changes and pioneered molecular biology.
In 1868, Swiss scientists isolated DNA, until 1953, when Crick and Watson discovered the structure of DNA.
Science seems to be advancing by leaps and bounds, and human rational progress is actually a long-term and slow thing, but it can also give us a more lasting belief.

John M. Barry




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